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Signs and symptoms of possible substance use

Early recognition, reporting and intervention are crucial for patient safety and helping colleagues recover


  • deterioration in appearance/personal hygiene
  • complaints of headaches or physical ailments
  • skipping meals
  • pinpoint or dilated pupils, runny nose, watery or bloodshot eyes
  • sweating, flushed face, bloating
  • tremors, restlessness
  • marked nervousness, anxiety
  • diarrhea and vomiting
  • abdominal/muscle cramps
  • change in weight
  • smell of alcohol on breath; frequent use of breath mints, gum or mouthwash
  • slurred speech
  • unsteady gait

Personality and mental health

  • mood swings
  • irritability, defensiveness
  • confusion, memory lapses
  • inappropriate responses/behaviours
  • withdrawal, isolation from colleagues
  • lack of focus/concentration and forgetfulness
  • lying and/or providing implausible excuses for behavior
  • family problems, issues at home, financial or legal problems
  • not keeping appointments

Performance and professional image

  • repeated attendance issues with a pattern (sick after days off); calling in sick a lot
  • volunteering for overtime
  • moving to a position where there is less visibility or supervision
  • arriving late for work, leaving early
  • long breaks or lunch hours; sometimes without telling colleagues
  • frequent or unexplained disappearances from the unit
  • errors in judgment
  • gradual decline in performance; doing enough work to “get by”
  • sleeping on the job
  • excessive number of incidents/mistakes
  • not following policies

Drug diversionary behaviours

  • failing to have narcotic wastage observed/cosigned
  • performing narcotic counts alone
  • tampering of packages or vials
  • waiting until alone to open narcotic cupboard and/or draw up medication
  • using fictional client names on narcotic records
  • frequent revisions/discrepancies on narcotic records
  • inconsistencies between narcotic records and clients’ MARs
  • frequent reports of lost or wasted medications
  • asking to be assigned to clients receiving large amounts of pain medication

The signs and symptoms listed above are not exhaustive list. Many of the symptoms can be associated with other pathologies and diagnoses.

Thank you to the Nova Scotia College of Nursing for their permission to adapt Appendix A of their Problematic Substance Use: A Guide for Nurses Practice Guideline​.

Review the related case study

Reporting substance ​use: your responsibilities